Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1–4

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014–2017) since NELA was established.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>patient-level data were populated from the NELA data set years 1–4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P &amp;lt; 0.001) and 90-day mortality (20.4 versus 7.2%, P &amp;lt; 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P &amp;lt; 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P &amp;lt; 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1–4 (8.5 to 16.5%, P &amp;lt; 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35–0.42, P &amp;lt; 0.001; 90-day OR 0.6, CI 0.56–0.65, P &amp;lt; 0.001).</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.</jats:p> </jats:sec>

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

“…Involvement of a physician specialized in the care of older adults to co-manage these patients, and/or the use of targeted interventions should occur as soon as possible and is associated with better outcomes. The strongest evidence for comprehensive geriatric assessment exists for patients with hip fractures [92][93][94][95], but a recent paper shows postoperative geriatrician review was associated with reduced mortality in patients over the age of 65 years undergoing emergency laparotomy [26,96]. Another recent study using a proactive approach for patients over 65 years presenting for emergency general surgery with integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices, promotion of patient-oriented rehabilitation, and early discharge planning found a significant reduction in mortality, length of stay and discharge to a higher level of care [95].…”

Mortality following emergency laparotomy: a Swedish cohort study

“…Emergency laparotomy (EL), a highrisk procedure, is a cornerstone of emergency surgery and is often performed when the clinically impaired patient requires urgent surgery for an acute abdominal condition. Although the underlying pathology varies, patients undergoing EL can be seen as a subgroup in the field with high mortality, especially among the elderly with comorbidity [6,7]. International studies report a 7-21% short-term mortality rate, a long overall stay in hospital and a large number of ICU admissions for patients undergoing EL [6,[8][9][10][11].…”

Sharing the helm: medical co‐management for the older surgical patient

“…Collaborative care models have shown better care coordination, 29,31 decreased complications including delirium and functional decline, 31,32 shorter hospital stays 31,32 and potential cost savings 33 . Observational data from the National Emergency Laparotomy Audit (NELA) in the United Kingdom (UK) show that postoperative geriatrician review is associated with lower mortality in older emergency laparotomy patients, 34,35 while meta‐analyses of studies of co‐management of surgical patients by geriatricians 36 or general physicians 37 suggest that mortality benefits accrue in models including a multidisciplinary team in addition to the medical specialist. There are also concerted efforts on improving perioperative care for older people undergoing elective surgery, proactively identify issues in the preoperative setting to predict and reduce complications postoperatively.…”